Patient Preparation, Positioning, and Transport
This domain tests the perioperative journey before incision: verification, skin antisepsis, safe transport, and positioning that protects nerves, skin, and breathing. Exam stems are usually about a patient who is positioned, moved, or prepped incorrectly, and you must identify the injury risk or the required corrective action.
Preoperative preparation
Confirm identity, procedure, site and side, consent, allergies, NPO status, and required implants against the record. NPO is generally 8 hours for fatty or solid food and 2 hours for clear liquids, per anesthesia policy. Hair is removed with clippers immediately before surgery when removal is truly necessary - razors create microabrasions that raise infection risk. Skin prep combines friction, a contact time, and full drying: chlorhexidine-alcohol is common for skin, povidone-iodine for mucous membranes and the eye area. Alcohol-based preps must dry completely and must not pool under drapes near electrosurgery or lasers.
Transport and transfer
Transport with at least two staff, side rails up, safety straps secured, lines and drains supported, oxygen and monitoring maintained, and the patient never left unattended. Handoffs include identity, procedure, allergies, lines, and any implants or prosthetics.
Positioning principles
Positioning balances surgical access against physiology: maintain alignment, pad all pressure points, secure the patient with a strap, protect the eyes, and keep arms abducted no more than 90 degrees to avoid brachial plexus stretch. Anesthetized patients cannot report pain or numbness, so nerve injury is silent. In the lateral position an axillary roll sits about 2–3 cm below the axilla, protecting the neurovascular bundle from the patient's own weight; a pillow between the knees prevents pressure between legs, and the dependent leg is slightly flexed. In lithotomy, stirrups are level, hips are not over-flexed, and the peroneal nerve at the fibular head is padded. Prolonged Trendelenburg raises aspiration and facial edema risk. Document position, devices, and any padding used.
Worked example
A patient is placed lateral for a thoracotomy and the circulator places the axillary roll directly in the axilla. That compresses the very brachial plexus and axillary vessels the roll is meant to protect. The roll belongs 2–3 cm below the axilla over the chest wall, with the down arm supported forward and the head aligned with the spine.
Traps that cost marks
Arm abduction beyond 90 degrees; unpadded elbows and heels; repositioning after the table is turned without rechecking lines and padding; skipping a repeat verification after transfer.